TThhee EEccoonnoommiicc IImmppaacctt ooff PPrreevveennttiioonn A report prepared by The Center for Public Health and Health Policy at The University of Connecticut Health Center and The University of Connecticut, Storrs June 2008 The Center for Public Health and Health Policy (CPHHP) was established as a University-wide Center in 2004. It serves as “the central organizing and implementing force in public health for teaching, research, and service activities…that…will enable the University to speak with one voice to any and all interested agencies and other constituencies regarding established or new needs in public health education and research of significance for all of our citizens throughout the State and the region.” (President Philip Austin, November, 2005) On the Cover: Hygeia, Greek goddess of prevention Prepared By: Brian L. Benson, MPP Eileen Storey, MD, MPH Charles G. Huntington, III, PA, MPH Mary U. Eberle, JD Ann M. Ferris, PhD, RD © June 2008, University of Connecticut The Economic Impact of Prevention Executive Summary From 2005 to 2006, U.S. health care spending increased 6.7 percent to $2.1 trillion, or $7026 per person. The most recent state estimates show that in 2004, total health care spending in Connecticut was over $22 billion or $6,344 per person, which at that time was 20 percent higher than the national average. Health care spending in the United States is expected to continue to increase during the next decade, and is estimated to reach $4.3 trillion in 2017, or $13,101 per person. If health care spending in Connecticut continues to exceed national estimates by 20 percent, it could reach $26.4 billion in 2017, or $15,721 per person. While U.S. per capita health spending is the highest in the world, U.S. health outcomes lag behind those of most other industrialized countries. High health care costs in the face of suboptimal health outcomes suggest that the U.S. is getting poor value for its health care dollar. In contrast, a large body of evidence from a wide variety of sources suggests that investments in prevention produce value in health care spending, increased productivity and improved quality of life. Evidence clearly demonstrates the In an effort to contribute to current dialogue regarding health benefits and health system reform, the Center for Public Health and Health Policy at the University of Connecticut reviewed the economic value of existing evidence on the effectiveness and cost-effectiveness of prevention. The disease and injury prevention and health promotion. In impact of benefit economic terms, the Center’s task was to elucidate the nature and extent of the evidence that demonstrates cost- and value is effectiveness of disease and injury prevention programs and greatest when clinical prevention services. prevention is Key Findings: implemented at the earliest • Evidence clearly demonstrates the health benefits and opportunity. economic value of prevention. The impact of benefit and value is greatest when prevention is implemented at the earliest opportunity. • Primary prevention forestalls or blocks the onset of disease, thereby avoiding or delaying the costs associated with treatment and lost function. For example, immunizations reduce the transmission of infectious diseases and thereby reduce the costs associated i with treatment and other economic effects (e.g., reduced wages and productivity) of acquired disease. • Secondary prevention takes the form of the early detection of asymptomatic diseases through screening. Early detection enables the interruption of the disease process at a point when treatment costs are less, when health and functioning can be preserved or more fully restored, and when related costs such as work absence are less. For example, cholesterol screening identifies asymptomatic persons at increased risk of coronary artery disease, which when untreated leads to significant increases in preventable death, disability, and medical expenditures. • Tertiary prevention services intervene when a disease or injury has already occurred. Tertiary prevention seeks to limit relatively expensive hospitalizations and improve quality of life through the effective management of symptoms. Disease management programs have emerged as the cornerstone of tertiary prevention. • Besides the traditional three dimensions of primary, secondary, and tertiary, prevention and health promotion interventions occur across a risk-reduction continuum that includes individualized interventions, clinician-directed services, and community- and employer- based strategies. For example, primary prevention of type II diabetes might include a built environment that facilitates walking, biking, and other safe opportunities for exercise in the community, and individualized and workplace exercise At the individual level and diet programs. The secondary prevention entails making prevention of diabetes might include healthy choices as a result of screening for early detection and diet and exercise counseling to delay onset. education and an Tertiary prevention might include a environment that influences disease management program to and supports good choices. prevent serious complications of diabetes such as blindness and amputation. • At the individual level prevention entails making healthy choices as a result of education and an environment that influences and supports good choices. Smoking, poor diet coupled with physical inactivity, and alcohol consumption were the leading actual causes of mortality in the United States in 1990 and again in 2000 and are significant drivers of health care utilization. Prevention programs and interventions are effective in supporting and encouraging healthy behaviors. • Health care and health spending are not distributed uniformly in Connecticut, resulting in severe health disparities by race/ethnicity, income, education, and geographic location. Maintaining or improving the health of all state residents in coming years will require investments in prevention, particularly at the population level that encourage and support healthy behaviors, reverse or slow growth in rates of chronic diseases, and improve service delivery for underserved populations. Specific strategies need to be ii developed that effectively deliver preventive services to, improve the health of, and support healthy behaviors among, minority populations. • Connecticut neither maximizes investment in prevention nor receives optimal benefits of prevention for state-covered populations (e.g., state employees, persons covered by Medicaid, and the uncompensated care pool). Improved delivery of prevention programs and services is possible despite existing regulatory and structural restrictions. Throughout the course of the Center’s investigation, many questions arose. Most notably: • What is the impact of growing burdens of chronic disease on health spending? • Which characteristics of our health system constitute barriers to the implementation of prevention programs? • What are the implications of universal health insurance coverage for prevention and vice versa? Chronic disease Chronic diseases have emerged as the major drivers of health care costs, as well as associated economic losses. The explosion in the rates of chronic diseases that intensify treatment levels and escalate spending is in large part due to unhealthy behaviors. Medical advances have also increased survival into old age resulting in many elderly people living with multiple chronic conditions. However, many chronic diseases are amenable to primary, secondary, and tertiary prevention services. The burden of chronic diseases such as heart disease, cancer, depression, hypertension, and type II diabetes could be greatly reduced if proven clinical and community preventive measures were fully implemented. Structural frameworks The Center’s analysis of the cost- effectiveness of prevention services is Controlling the growth of future driven by three fundamental health costs rests on the ability to characteristics of the U.S. health care system. First, the U.S. lags behind prevent proactively, detect early, most other developed nations in regard and manage well the diseases that to the effectiveness and efficiency of its drive health care costs. health care system. Second, significant disparities in specific measures of health, life expectancy, and quality of life exist along the lines of gender, race and ethnicity, income, education, geography, disability status, and sexual orientation. And, third, the flow of resources in the U.S. health care system is heavily skewed toward the diagnosis and treatment of disease and injury. The market forces that drive the current health care system produce medical care rather than healthy individuals and populations. iii Implications of universal health insurance Prevention is an integral part of the discussion as the United States moves toward universal health insurance. Current efforts in Connecticut to address the lack of coverage for over 350,000 residents create both an opportunity and a need to invest in a health system with a focus on prevention. Only a health system that enhances access to proven disease prevention and health promotion services has the potential to control costs and improve health outcomes in the long term. As the evidence described in this report indicates, getting the most value for the U.S. health care dollar requires shifting the focus from medical treatment to population-based prevention. Controlling the growth of future health costs rests on the ability to prevent proactively,